This is a follow-up letter regarding my retirement as
liaison between the Board, the Legislature and all California Licensed Midwives.
As you know, this role was taken over on July 29th by Licensed
Midwife Carrie Sparavohn, Chairwoman of the California Association of
Midwives. I will continue to represent members of the California College of
Midwives and be available to consult, especially in regard to professionalism
of licensed midwives, quality of care issues and the appropriate standards of
care for community-based midwifery practice.

I want to thank all the members of the Board and the
staff for their kindness and help through out the many years. I know it hasn’t
been easy for any of us and I particularly appreciate the many times they went
the extra mile on behalf of California Licensed Midwives. Strange as it may
seem, I will actually miss you all and my regular attendance at the quarterly
Board meeting.

I attended my first Medical Board meeting May 3rd,
1993. In the following 11 years I have been present at two to four meetings
each year and attended all seven of the midwifery licensing implementation
committee meetings held in 1994. For me, the last decade has been a crash
course in administrative law, the medical justices system, the history of
midwifery legislation in California and learning about the physician and lay
appointees to the Board and the hard-working and dedicated people employed as
its staff. I made many important friendships that I will always treasure. I
particularly enjoyed being a useful source of information about the
physiological management of normal birth, the safety of community-based
midwifery and the risks of medicalizing maternity care for healthy women with
normal pregnancies.

Unfortunately, the
history and circumstances that preceded my political activism on behalf of LMs
is not such an uplifting story. From 1981 to 1991 I practiced midwifery
lawfully, peacefully and without incident as a Mennonite Midwife under the
religious exemptions clause. Without any precipitating consumer complaint or
bad outcome, two agents of the Medical Board came to my home on August 9th,
1991 and served me with a criminal warrantcharging me with five misdemeanors. I was
immediately arrested and handcuffed in presence of my youngest daughter and
transport to the Santa Clara county jail, where I was held in solitary
confinement for 13 hours until members of my community could raise $50,000
bail. It’s noteworthy that in 1991 the boxer Mike Tyson had just been arrested
and charged with felony rape. His bail for rape was $30,000. The misdemeanor
charges against me required that my community to pay out $5,000 cash to a bail
bondsman. As you know, bail money is a non-refundable fee.

According to a radio news report attributed to the
Associated Press, the San Mateo office of the Medical Board stated that I was
arrested as a test case in regard to the religious exemptions clause. They
were hoping my prosecution would establish a precedent that would eliminate
the traditional practice of non-medical midwifery under the religious
exemptions clause. This incident occurred under the direction of Ken Wagstaff,
the executive director of the MBC at the time.

After 20 months of pre-trial hearing (and $30,000 of legal expenses), the DA
admitted that the non-medical practice of midwifery was statutorily neutral,
i.e., it was not a crime. He told my lawyer and me that he was aware of
the lack of statutory basis for criminalizing traditional midwifery and said:
“I called
those guys at the Medical Board and I told them that if they wanted me to keep
prosecuting midwives, they were going to have to get some new legislation
passed.”

Within a few weeks of this conversation, the criminal prosecution against me
was mysteriously dropped (in its 20th month!) and the legality of
my practice under the religious exemptions clause was formally acknowledged in
the same court documents that dismissed the charges against me. I attended my
first Medical Board meeting in Sacramento five days later (May 3, 1993), which
was how I discovered that public participation in the public meetings of the
agency was virtually non-existent, a fact that I interpreted to mean that
crucial element of democratic process – in this case public oversight -- was
functionally absent.

Since the mission of the Board is public/consumer safety, I considered this
lack of public participation to result in a patronizing and paternalistic
process that was just plain poor public policy. This was the major motive in
the many written requests by me for the quarterly board meetings to be video
broadcast over the Capital’s cable system, so that citizens all over our great
big state could remain informed and informing. It also explained a lot about
how the agency, under Mr. Wagstaff’s command in 1991, could have used its
authority in such an irresponsible manner. In targeting me as a member of a
class for the purposes of a ‘test case’, the agency misappropriated the
considerable powers of California state government to carry out the
long-standing agenda of organized medicine to eliminate all forms of health
care by non-physician care providers. I guess I’m just old-fashioned enough to
believe that our state government shouldn’t be used to carry water for
organized medicine.

Shortly after the criminal charges against me were dropped, the CMA approached
Senator Killea with a deal – if she would let them gut the pending midwifery
legislation authored by her in cooperation with the midwives and permit it to
be replaced by a licensing statute identical to nurse-midwifery (complete with
the same poison pill of mandatory physician supervision), the CMA would
guarantee its passage. During one of the Assembly hearing on SB 350, Senator
Killea explained to me that: “Bad
legislation is better than no legislation at all”.
With this collection of precipitating events, the LMPA of 1993 was passed and
the same Medical Board that was responsible for the arrest and criminal
prosecution of midwives was now identified as the regulatory body for midwives
like myself. In a nutshell, that is the story of how I came to be
traumatically bonded to the Medical Board. “Those guys at the Medical Board”
may just be stuck with me for life, as I am a firm believer that the
democratic process is a necessary ingredient in any effort to ‘protect’ the
public.

In
light of these disturbing experiences and my inauspicious entry in the medical
justice system, followed by eleven years of representing LMs to the Board, I
believe that I have earned the right to offer some observations on the topic
of midwifery and the relationship between the Medical Board, professional
midwives and the obstetrical profession. At 61 years of age, I am old enough
to have seen profound social changes, both in how medicine is practiced and in
other topics relative to social justice. I believe in working for social
justice. I am fundamentally optimistic that in my life time I will see the end
of the prejudice against midwives.

Background Remarks

But before I get to specific remarks about midwifery
licensing, I’d like to tell you two short but informative stories about my
early life in a deeply segregated society. As a teenager, my Canadian
Mennonite family moved to Florida in 1957 and for the first time in my life, I
was exposed to and shocked by blatant and institutionalized racial prejudice.

I attended segregated public schools, I trained as a
nurse in a segregated hospital and I eventually provided maternity care in the
same segregated institution. Living up close and personal with
institutionalized prejudice and government sanctioned segregation I had two
very instructive experiences that I want to share with you.

The first story is about the public restrooms at a
local gas station. Instead of the usual arrangement of two restrooms, one for
each gender, the Bay station had three bathrooms. Big signs on each of the
three doors proclaimed either ‘White Ladies’, ‘White Gentleman’ or simply
‘Colored’. Today we all can see this violation of common decency as emblematic
of a morally-bankrupt system that was dehumanizing and wrong. It needed to be
changed and eventually it was. Wonder of wonder, I personally lived long
enough to see institutionalized segregation in the South come to an end. I
believe this to be an example that right does win out if one is willing to
work for it and wait for the process to come to fruition.

I had a second remarkable and life-changing
experience as a nursing student and a staff nurse working in the labor and
delivery room of that same racially segregated hospital in the 1960s. Due to
its system of medical apartheid, I got to closely observe and directly
participate in two entirely different systems, side by side, in the same
hospital, at the same time, with the same staff and the same type of patients
but totally different management style and outcomes, different as day
and night.

It was a
naturally-occurring, one-of-a-kind scientific study contrasting two styles of
maternity care – a profoundly interventionist model characterized as “knock’em
out, drag’em out” obstetrics, versus a lazier-fair system that resulted in,
ipso facto, physiologically-managed maternity care. It all depended on
whether the mother was black or white.

In our segregated hospital, Caucasian mothers were sent
to the all-white labor ward on Five-North. On admission they were immediately
given 3 grams of barbiturates (a double dose of sleeping pills). As labor
progressed they were injected every 2-3 hours with a narcotic mixture known as
“twilight sleep” – large and frequently repeated doses of Demerol,
tranquilizers and scopolamine, an hallucinogenic drug that also caused
short-term memory loss and amnesia.

Under the influence of these powerful drugs some women
became temporarily psychotic and physically fought with the staff and even bit
the nurses. Left unattended, they fell out of bed, chipped teeth or broke
arms. To keep drugged women from getting hurt, the hospital required a nurse
to stay right at the bedside through out the entire labor. However, we often
delivered 8 to12 patients a shift. When the nurses were busy, our white
mothers were put in four-point leather restraints, the same ones used in the
locked psychiatric wards of the hospital. This forced women to labor flat on
their back, a position that interferes with and reduces blood flow to the
uterus and placenta, making labor extremely painful and often causing fetal
distress.

When time came to give birth, these mothers were moved by
stretcher to the Delivery Room, given general anesthesia, put in lithotomy
stirrups, a “generous” episiotomy was performed, and the baby was extracted
via ‘low’ forceps. One of my jobs as a nurse in the all-white Five-North
delivery room was to resuscitate these deeply narcotized and respiratorily-depressed
babies. Out of every 25 babies, one or more would fail to establish
respirations, thus dying as a result of the drugs, general anesthesia and/ or
the use of obstetrical instruments. This high mortality rate was iatrogenic in
origin, but that has never been recognized or acknowledged by the obstetrical
profession. And yet, this high perinatal mortality rate is still within living
memory. For older physicians, these memories add to the mythology that normal
birth is intrinsically dangerous and requires many medical interventions.

After the baby was delivered, the obstetrician inserted
his hand up into the mother’s uterus to pull out the placenta. Then the
episiotomy incision was sutured, with particular attention paid to the
so-called “husband stitch”, which was to make things tight for woman’s
husband. As an 18 y/o student nurse, I was appalled. It should be noted that
the third leading cause of maternal mortality in the 1950 and early 1960s was
anesthesia-related deaths.

Then as a student nurse I was rotated off Five North to
One South, the black ward in the basement of the hospital. Oddly enough, the
maternity care for black mothers was remarkably simple, straightforward,
non-interventive, and in my humble 18 y/o opinion, infinitely more humane. It
was also psychologically-sound and made right use of gravity. As judged by the
number of newborns who did not need resuscitation at birth, it was
vastly more successful than the highly medicalized care visited on their
Caucasian counterparts upstairs on Five North. Frankly, this was all a big
relief to me, as I no longer felt that I was being asked to be an agent for a
process that was clearly and immediately harmful to mothers and babies.

On One South, there was no labor ward or labor room nurse
to care for black mothers. These laboring women were just admitted to their
postpartum beds in an old-fashioned four-bed ward. Their labors were not
accelerated with Pitocin or any other drugs. Neither were they given
medications for pain because the two staff nurses, who were responsible for
40-plus other patients, had no time to labor-sit with drugged and combative
women having hallucinations. Besides, in a segregated society, no one much
bothered about the labor pain of black mothers, who were assumed to either be
tough and able to take it or just out of luck.

However, there were many unintended advantages to this
system of purposeful neglect. Because they were unmedicated, our black women
in labor were permitted to walk around freely and socialize with the many
other experienced women on the ward. This was very comforting to them and
provided a useful source of encouragement and tips on how to cope with an
unmedicated labor. In particular, our black mothers avoided lying in the bed,
preferring to stand and sway or squat during contractions while holding on to
the bar at the foot of the bed. When I asked why they didn’t just get in the
bed, they looked at me like I must be really dumb and answered in an irritated
voice: “Because it hurts too bad when you lay down”. How right they were!

Eventually one of our maternity patients would start to
make those unmistakable pushing sounds and so we grabbed a stretcher, threw a
sheet over the laboring woman and made a mad dash for the elevator, hoping to
get up to the delivery room on Five North before the baby was born. However,
so many mothers were high parity that we routinely did not make it. I got my
first experience as a “midwife” by receiving the spontaneously born babies of
black mothers who delivered on the stretcher in the elevator half way between
One South and Five North.

The ease and simplicity of these nurse-managed,
non-medicalized births was in stark contrast to the invasive methods used by
obstetricians on our Caucasian patients on 5 floors above. As nurses talked
these black mothers through the last couple of pushes, their babies just
slipped out, with little fuss. And wonder of wonder, these spontaneously-born
breathed on their own, since their mothers had not been medicated or
anesthetized and no artificial, forcible or mechanical means were used to
force the labor or extract the baby. There was no painful episiotomy, no river
of blood issuing forth from a gapping perineal wound, no forceps, no fundal
pressure, no bulb syringe jammed repeatedly down the baby’s throat, no manual
removal of the placenta, no stitches, no post-anesthesia vomiting, no
artificial separation of mother and new baby. Clearly Mother Nature, when
respectfully supported and un-meddled with, does a darn fine job.

By today’s legal
standards these black mothers were actually receiving “substandard” care.
Racial prejudice and discrimination of the era had institutionalized the
negligent treatment of them and their unborn or newborn babies. Yet, they
clearly were getting the better end of the deal, as black mothers were not
made to suffer the routine indignities and painful interventions in their
labor that were the inevitable lot of while women. The black mothers on One
South got safer, physiologically managed labors and normal spontaneous births.
As a result, they were not subjected to the labor-retarding effects of social
isolation, to being immobilization on their backs with four-point psychiatric
restraints, to the maternal effects of being profoundly narcotized or to the
slowly healing episiotomy that made it hard to sit and difficult to care for a
new baby. Their babies were not exposed to intrauterine narcotics and
resulting fetal distress and did not need to be resuscitated, thus
contributing to increased IQ points.

When expecting my first
baby I took a lesson in childbirth out of that same book. In an attempt to
avoid the detrimental effects of these interventions, I asked my obstetrician
if I could have the same kind of care that our black mothers received. He
smiled and suggested that I just stay out of the hospital until the baby was
ready to be born because “that’s what hospitals are for -- drugs and
anesthesia”. So I labored at home as long as possible, hoping against hope to
have a nice nurse-managed birth on a stretcher in the same elevator on the way
up to the Five North delivery room. As luck would have it, I misjudged by just
a few minutes. While my husband drove the car, I gave birth alone in the back
seat of our Renault, five blocks before we got to hospital. That was the
second major area of my experience in midwifery.

Modern Times, Modern
Problems

For the last 100 years the obstetrical profession in the
United States has gone to great lengths to convince all of us that
physiological management is old-fashioned, inadequate and down-right
dangerous. They have purposefully dismantled the infrastructure for providing
physiological management, claiming that care for normal childbirth, at least
for the affluent and the Caucasian, should consist of a constant stream of
medical and surgical interventions provided by physician-surgeons in an acute
care hospital setting. When it comes to the astronomical expense of the
interventionist model (particularly the maternal choice or ‘elective’
Cesarean), the sky’s the limit, because we are repeatedly assured that this
extravagance is buying us better babies.

This is the origin of the conflict we are experiencing
today between independent midwifery and organized medicine. They seek to shoot
the messenger, as midwives are messengers for normal birth and physiological
management. Representatives of A_COG have appeared before the Board many
times, trying to convince you that licensed midwives are dangerous because we
do not medicalized normal birth with the routine use of drugs and surgical
procedures.

At present, A_COG has identified a troubling example of
biased obstetrical research and media sensationalism as the centerpiece of it
objections to midwifery.A_COG would like Board members to think that
this study – “Outcomes of Planned Home Birth in Washington State” -- is a
comprehensive form of research that defines the scientific literature on the
risks of home-based midwifery care. They insist it stands head and shoulders
above all previous research, negates all previous findings and is able
to determine, once and for all, that planning a home birth is fundamentally
dangerous, end of conversation. Unfortunately, this example of junk science
violated virtually every principle of good science in its design, its
collection and interpretation of the data, the reporting of its conclusions
and its ethical relationship to the scientific community and the public.
(A brief critique of this study
is enclosed.)

However, we all know
that if the physiological management of normal labor and birth by professional
midwives in non-medical setting actually represented the kind of danger
that A_COG repeatedly claims, they would have gone to court ten years ago
to obtain an injunction against the implementation of the LMPA and
practicing of LMs. A_COG didn’t do that because the factual basis for
doing that didn't exist. While
these unsubstantiated and self-serving claims may fool the lay public, they
could not standup under the rules of evidence in a court of law. A consensus of the
scientific literature not only supports physiological management in all
settings for healthy women (homes and hospitals), but the
scientific literature also comes to the conclusion is that in general,
physiologically-managed care is actually safer and more cost effective for
healthy women than obstetrical intervention. Non-interventive physiologic
management is the type of maternity care
used world-wide. It provides superior maternal-infant outcomes as compared
with the United States, with far less expenditure of money and finite medical
resources.

Historically the obstetrical profession does not have a
good track record at changing its practice as scientific evidence demonstrates
that customary treatments are ineffective or harmful. In spite of scientific
evidence supporting physiological management as the appropriate standard for healthy
women, organized medicine tries to justify the medicalization of all normal
labors, while perpetuating its bias against science-based maternity care and
its prejudice against midwives. In its own way, it is an institutionalized
system of apartheid in which mothers and midwives who employ physiological
management are discriminated against. Access to obstetrical services is
blocked and when those services become a medical necessity, both midwives and
mothers are often the victims of retaliation by angry and outraged
obstetricians, who in fact do outrageous things with social impunity.

Before the passage of midwifery licensing laws, the
strategy of organized medicine was a sudden-death playoff that used criminal
arrest and the prosecution to achieve its goals. Since the passage of the LMPA,
the strategy to eliminate professional midwifery is death by a thousand razor
cuts, as organized medicine fights the practice of licensed community midwives
at every turn, with every dirty trick and with just as much enthusiasm as
before. If A_COG were to wear a campaign button in their war against
independent midwifery, they would take their slogan Bull Conner – the
infamous, segregationist sheriff of Birmingham, Alabama who wore a button said
“NEVER”.

The medical profession has always had an extremely
contentious relationship with any scientific discover or theory that
threatened established doctrines or practices. Notorious examples are the
rejection of the stethoscope, the germ theory of contagion and accurate understanding of
the circulation of blood. Bitter controversies between doctors and other
scientists that went on for many decades and many ruined careers preceded the
grudging acceptance and eventual widespread use of these discoveries.

A more modern example of unscientific and harmful practices
widely employed includes the routine prescribing of estrogens for pregnant women in the 1950s,
which resulted in vaginal and penile cancer in DES adolescents. Even more
recent and wide-spread was the routine prescribing of estrogen for
post-menopausal women, based on the unproven theory that this drug would to
protect against heart disease and cancer when, in fact, it increased the rate
and severity of the very diseases it was supposed to prevent. Recent examples
that include the same kind of ridicule and vigorous rejection of new theories
as suffered by Dr. Semmelweis over a hundred years ago was also visited on Dr.
Heimlich, the physician who developed the Heimlich maneuver (for choking) and the Australian
doctor who discovered that stomach ulcers were caused the
Helicobacter pylori bacteria .

The History of Obstetrics

However, the obstetrical profession has and
continues to have the most abysmal track record whenever scientific evidence
shows their customary practices to be ineffective or harmful. The historical
record shows that time and again the obstetrical profession has resisted and
rejected scientific knowledge if it refuted their favorite theories or
required a change of practice. The most disturbing and well-documented
display of this regrettable trait comes from the 19th century story
of Dr. Philip Semmelweis, who was a professor of obstetrics at a prestigious
teaching hospital in Vienna during the 1840s. Dr Semmelweis amassed
incontrovertible proof that purulent organic material carried under the
fingernails of doctors and med students caused the fatal puerperal sepsis. It
was this infection, commonly known as ‘childbed fever’, that caused the death so many newly
delivered women. In his own words Dr. Semmelweis concluded that: “puerperal
fever is caused by the examining physician himself, by the manual introduction
of cadaveric particles into bruised genitalia”

Unfortunately the obstetricians of Dr. Semmelweis’ day,
like Bull Conner, also said “never”, only this time it was to the idea
that childbed fever (or any other complication of childbirth) could possibly be caused by
poor obstetrical practices. The specific practice in question was doing
vaginal exams on healthy laboring women without having washed their hands
between the autopsy room and the labor ward. As a result of this dangerous
practice undelivered mothers became contaminated with the haemolytic
streptococcal bacteria and developed a virulent septicemia that caused death
within 72 hours. During the 18th and 19th centuries up
to fifty percent of maternity patients (both mother and baby) died in
the teaching hospitals of Europe from haemolytic septicemia. According to
historical records, the all-time worst epidemic of contagion occurred at the
University of Jena, when not a single mother left the hospital alive for four
years.

The “usual and customary” practice of obstetrics in the
19th century included the post-mortem dissection of women who died
during or after childbirth. In this regard Dr. Semmelweis and his colleagues were
privy to a lot of educational ‘opportunities’. In association with these
routine autopsies, cadavers were also used to for training purposes to demonstrate the mechanics of
obstetrics and permit students to perfect their use of obstetrical
instruments. Prior to this era, a biologically-safe teaching manikin,
developed by French midwife Madame Cordray, was used to teach midwifery skills
to student midwives and instrumental and manipulative obstetrics to physicians
and medical students. These life-size teaching manikins each had an
anatomically correct pelvis, pregnant uterus occupied by a realistic fetal
doll, amniotic fluid, placenta and umbilical cord and access to uterine
contents thru a working genital tract.

As dissection became a more important part of medical
school education (early 1800s) the obstetrical manikin fell out of favor all across Europe.
Gradually the bio-safe manikin was replaced by the bio-hazardous cadavers of
women who died in childbirth, with the assumption that such cadavers were a
“superior” teaching resource that would result in a superior medical
education. Each body of each woman to be used for teaching purposes was severed in half at
the waist, the viscera removed and the uterus dissected out. This was to
prepare the amputated and hollowed out lower half of the body to receive a
recently deceased newborn, which was placed inside the pelvis for teaching
purposes. By passing a series of dead babies down thru the disarticulated
pelvis of a childbearing woman who recently died, a professor of obstetrics could control
the learning experience and assist his medical students to could carry out
vaginal exams, determine fetal lie and position, apply obstetrical forceps,
practice fetal destructive operations and learn life-saving maneuvers such as
podalic version for obstructed births.

Podalic version was an invasive procedure in which the
physician reached up into the uterus to turn a vertex (head down) fetus into a
breech position, so that an otherwise undeliverable baby could be pulled out
by the feet. Before the development of anesthesia and aseptic technique, which
would pave the way for safe cesarean sections, the only choices for an
obstructed labor was either a fetal destructive operation or delivering a
live baby via podalic version. However, the acquisition of all these
life-saving skills by medical practitioners came at an awful price, as the use
of cadavers for teaching virtually guaranteed that highly-contaminated organic
material would be carried into the labor wards by doctors fresh from the
dissection lab. The ironic consequences was to feed a cycle of fatalities in
the name of improved medical education and safer maternity care. In some hospitals, as many as 700 new mothers (and their
babies) died each year, or approximately two a day. In Vienna, 1,968 women died in Division One at the University of Vienna
hospital between 1841 and 1846. In Division Two, the midwifery program staffed
by graduate and student midwives, the mortality rate was only one fifth of that in Division One during the same period of time.

It is important to note then (as now) that many
knowledgeable people realized that harm being caused by the prevailing obstetrical
practices and spoke out about it.
This included other physicians and midwives who were all unwilling to settle
for superstitious explanations which blamed these fatal epidemics on everyone
and everything else except the harmful obstetrical practices. The
physician-director of
obstetrics in Semmelweis’ time had a list of 39 so-called ‘reasons’ for
maternal deaths, such as miasma (bad air), chilling, ‘milk’ fever, errors in diet,
maternal emotions that suppressed the flow of the lochia and the ‘unstable’
condition of women. What they all had in common was that each supposed cause
was indefinable, untreatable and/or unpreventable, and so completely
absolved physicians of any culpability or even the need to search for a cause
or a cure. On the contrary, obstetricians got to portray themselves as heroes,
saving women from viciously defective reproductive biology, no doubt a
lingering effect of God’s curse on Eve. This gender-based devaluation was
soon to be launched into the 20th century by another famous doctor from Vienna
-- Sigmund's Freud -- as idea that for women, their biology was their
"destiny".

Over the course of the previous century a small but
substantial number of astute physicians all over the world – Doctors White in
England, Gordon in Scotland, Cederskjšld in Sweden and our own Oliver Wendell
Holmes in Boston -- had all observed, studied and warned of the iatrogenic
nature of childbed fever. This conclusion came from noting that repeated virulent
epidemics of puerperal fever were virtually absent in places that midwives
(who did not use surgical instruments or do autopsies) managed normal birth instead of doctors (who
did). An article by Oliver Wendell Holmes appeared in the
New England Journal of Medicine and Surgery in 1843, entitled ‘The
Contagiousness of Puerperal Fever’. In this he agreed with Doctors White and
Gordon that the disease was often transmitted, via an unknown agent, by both
physicians and nurses. Unfortunately, so-called ‘radical’ life-saving ideas
like aseptic technique and hand-washing were
ridiculed and dismissed as absurd by those who thought it inconceivable that
the healing hands a physician (or his instruments) could ever, under any
circumstances, be a vector for a contagious fatal illness.

History records that Dr. Phillip Semmelweis reformed
these iatrogenic practices by introducing prophylactic hand washing in a
chlorine of lime solution. Like a sudden overnight miracle, maternal
deaths in his institution fell from 18 % to 0.2% in the eight months
between April and December of 1847. As a result Dr. Semmelweis devoted his entire career
to preventing unnecessary maternal deaths by teaching and preaching the use of
asepsis principles. None-the-less his simple but effective
solution was ignored and ridiculed by his contemporaries, who could not wrap
their minds around something so unglamorous and straightforward, something
that would have required them to take responsibility for harmful practices and
make important changes in their profession.
For his trouble Dr. Semmelweis soon lost his prestigious post in Vienna’s most famous
hospital, lost his reputation and eventually his profession. As they say “No
good deed goes unpunished”. In the end he was driven mad by guilt
and his inability to “make them listen”. At the age of 47, a mere 21 years
after receiving his medical degree, he died in an insane asylum, leaving
behind a wife and several children.

The medical profession did not finally acknowledge the
role of contagion until 1881, when a French physician, the now famous Dr.
Louis Pasterur, established the central role of microbes -- commonly known as
‘germs’ or ‘pathogens’-- in causing illness and infection. On a chalk board at
a prestigious medical meeting Dr. Pasteur drew a graphic representation of
what the streptococcus bacteria looked like under a microscope -- rectangular
microbes that resembled a string of box cars on a train track -- and said
“Gentlemen, this is the cause of Childbed Fever”. With this discovery, Dr.
Pasteur delivered the fatal blow to the erroneous and dangerous doctrine of
‘spontaneous generation’ -- the theory held for 2000 years that life (and
infection) could arise spontaneously in organic materials.

The idea of surgical ‘sterility’ as we know it today is
little more than a 100 years old. Before this time the use of invasive
techniques and instruments were extremely dangerous and correctly seen by the
public as a method of “last resort”.It was
not until the discovery of anesthesia in the 1840s to control the inevitable
pain of surgery and 40 years later, the germ theory of disease and use of
sterile technique to prevent the infection that surgery became a reasonably
effective form of medical treatment. The first-ever obstetrical operation -- a
Cesarean -- was done in first century Rome to extract a living child from its
dead or dying mother. Anesthesia made it possible to do Cesareans on living
women and sterile technique made it possible for living women to
survivethe operation. Episiotomy, forceps and other invasive
procedures were also greatly enhanced by the use of anesthesia and sterile
technique. Obstetricians had such enthusiasm for these new technologies that
it didn’t take long for operative obstetrics to become the “wave of the
future”. By 1910, operative deliveries in one famous NYC hospital were
already up to 20% of all deliveries or one out of five births.

It would be lovely to report that the obstetrical
profession learned a valuable lesson from the regrettable era of Dr.
Semmelweis. I’d like to report that the profession has developed the habit of
evidence-based practice – scientific inquiry, listening respectfully divergent
opinions, taking feedback to heart and putting in necessary corrections.
However, scientific studies evaluating the mortality rate of obstetrical care
after the obstetrical profession eliminated the practice of midwifery
(approximately 1910 and 1930)showed just the
opposite. Instead of the vast improvement the promised by obstetricians,
there was a 15%
annual increasein maternal deaths for more than a decade and a
44% increase in neonatal birth injuries over the same period.The
escalating rate of mortality and morbidity was the direct result of replacing
the safer, physiologically-based care of healthy women (formerly provided by midwives)
by routine use of obstetrical interventions including general anesthesia,
episiotomy, forceps and manual removal of the placenta.

After more than a hundred years of resistance, the
obstetrical profession finally acknowledged the contagious nature of puerperal
sepsis. Better yet, they embraced the ‘new scientific method’ as hot, sexy and
vastly superior to the old days and old ways. Medical men (as they preferred
to be called) had always had a hard time distinguishing themselves from
midwifery, which was seen as low class, low pay ‘woman’s work’. The use of
obstetrical forceps and podalic version were favorite methods to rise above
the low status of midwives, but these were also associated with fatal
septicemias. Aseptic and sterile techniques promised to end these problems.

The obstetrical profession assumed (wrongly it turns
out), that if labor and delivery were simply conducted under conditions of
surgical sterility, all would be well regardless of the number of invasive
procedures performed. They assumed that the scientific advances of “modern”
medicine would now permit obstetricians to take control of normal childbirth
in a way they dared not do before.By
conducting normal childbirth as a surgical procedure, they could routinely
mechanize it thru the use of anesthetics, episiotomy, forceps and manual
removal of the placenta. With this kind of complete control over normal
(otherwise unpredictable) biology, they could dramatically speedup the
process. Obstetricians theorized that a faster, more controlled process would
be better for mothers, babies. And of course that same control and greater
speed was more conservative of the doctor’s time, more profitable for the
hospital and all around better for everybody. Entirely left out of this
picture were the classical principles of physiological management, which had been
discarded as irrelevant.

A century earlier, the power brokers of the medical world
all turned their backs on any evidence or suggestion that their practices
caused or contributed to maternal deaths from sepsis. For the next hundred
years, a new generation of obstetricians has turned their backs on
physiological process and rejected the principles of physiologic management. This highly invasive style of obstetrical care was still
in vogue in the 1960s and early 70s when I was a nursing student and L&D
nurse. The connection between the history of obstetrics and the issues of
‘modern’ obstetrics is not as remote as most people might imagine. Today, the routine interference in normal pregnancy andbirth
is the hallmark of contemporary obstetrics, in spite of the fact that this
‘style’ is also illogical, unscientific and harmful. In 1989 Dr. Iain
Chalmers, the Oxford University researcher who published the first
comprehensive review of evidence-based obstetrical practice (The Guide to
Effective Care in Pregnancy and Childbirth), bestowed the “Wooden Spoon
Award” on American obstetricians, with the disdainful comment that of all the
branches of medicine, our obstetrical practices were the least
scientific.

Like the movie Ground Hog Day or the folk song about the
man trapped on the MTA (Massachusetts Transit Authority), contemporary
obstetrics has trapped us in a vicious cycle that currently prostitutes the
historical ideals of medical care – “in the first place, do no harm”. The
issue is A_COG’s relationship with credible science and whether A_COG cherry
picks its research based on the organization’s hidden agenda. As in
Semmelweis’ day, modern-day powerbrokers continue to ignore scientific
knowledge that is inconvenient, unprofitable, refutes a favorite theory or
requires a change of practice. It happily uses junk science in an attempt to
discredit physiological management while providing obstetricians with a free
pass to employ ever increasing and ever more extreme interventions, including
the now popular “maternal choice” cesarean.

Solutions – Win-Win for everybody

I am here to testify to
two things – Bull Conner was wrong about segregation and so is the obstetrical
profession when it comes its prejudice against physiological management and
the medical apartheid of midwives. A long over-due and much needed reform of
our national maternity care policy will eventually bring an end to Flat Earth
Obstetrics. For the first time in modern times, maternity care for all healthy
women will be science-based and mother-friendly, which to say, it will
integrate physiological principles with the best advances in obstetrical
medicine to create a single, evidence-based standard for all healthy women.

When that happens,
physiological management will be the foremost standard for all healthy
women with normal pregnancies, taught to and used by all practitioners
(both physicians and midwives) and for all birth settings (home,
hospital, birth center). Then the so-called 'midwife problem' will resolve
itself on its own merits.

My question for the
members of this august body is simply this: “When history records the story of
this triumph of reason over prejudice, which side will you be listed on? Will
you know in your own hearts that you did what you could advance both science
and social justice? Will your relatives in future generations proudly count
you as a patriot for rights of healthy childbearing women to receive safe,
cost effective and science-based maternity care?

Today is September 11th,
2004. On that extraordinary day 3 years ago, a lot of ordinary people
became heroes because they were brave enough to go up the down staircases in
the Twin Towers to help people in need, irrespective of the obvious risk to
themselves. Hundred of these ordinary heroes died as a result of their courage
and commitment. Mother and midwives are not asking anyone to sacrifice life,
limb or livelihood for our cause. We are however asking for members of the
Board to go up the down staircase of medical politics. We are asking each
of you to go the extra mile, to make your decisions based only on the
consensus of the scientific evidence and to do the right thing just because it
is the right thing to do.

Enclosed as a separate attachment you will find a
critique of the study “"Outcomes of Planned Home Births in Washington State",
published in the ACOG Journal in August 2002. I believe you will find this
additional information useful in your dealings with representatives of A_COG.

On behalf of healthy childbearing women and their
faithful midwives, I thank you for your time and your attention.

Respectfully,

Faith Gibson, LM, CPM,

Executive Director, American College of Community
Midwives
Coordinator, California College of Midwives (ACCM state chapter)